Although the majority of countries in the world already have regulations for tobacco control, including those related to smoke-free areas policies, Indonesia only adopted a smoke-free policy in 2009. The country developed a smoke-free policy through Law on Health (Law No. 36/2009). Article 115, paragraph 1, of the Health Law states that “smoke-free places include health-care facilities, teaching-learning places, playgrounds, places of worship, public transport, workplaces and other designated venues”. Moreover, paragraph 2 of the Law on Health (Law No. 36/2009) creates an obligation for local governments to establish smoke-free areas in their territory. As a follow-up to this mandate, the Ministry of Health adopted the Joint Regulation of the Minister of Health and the Minister of Home Affairs No. 188/Menkes/PB/I/2011 and No. 7 of 2011 on guidelines for the implementation of a smoke-free policy in local governments. Government Regulation No. 108 of 2012 also regulates smoke-free areas in Indonesia. All of these regulations mandate local government to enact and implement the smoke-free policy.
The existence of smoke-free areas is a manifestation of the preventive function to reduce high smoking prevalence. Also, smoke-free areas are believed to be one of the mechanisms to reduce second-hand smoke exposure . The evidence about the implementation of a smoke-free policy in the United States through smoking prohibition in several smoke-free areas shows that it reduced exposure to cigarette components up to 72% and lessened the number of tobacco smoke . Studies of smoke-free policies show that there is a positive impact on the health of the entire population and a decrease in smoking prevalence numbers . A cross-sectional study from three cities in Indonesia (Jakarta, Palembang and Bogor) also found that there is urgency to implement a widespread, comprehensive, 100% smoke-free policy in Indonesia without exceptions for designated smoking areas .
The adoption of a smoke-free policy in Indonesia is a critical decision for protecting individuals from second-hand smoke and reducing the high rate of smokers. In Indonesia, 21.37% more men die caused by tobacco than on average in medium to high development countries . As shown in Figure 1, the highest smoking prevalence is in West Java Province, at 32.7% of the population . Male smokers dominate the prevalence of tobacco use in Indonesia. Besides being known as the world's fourth-highest consumer of cigarettes, Indonesia is also known as the “baby smokers” country .
The prevalence of tobacco consumption in Indonesia at the age of 10–14 shows an increase from year to year. The overall number of smokers in 2013 increased 12.3 times over the number in 1995 . This figure places Indonesia as the fourth-highest country in terms of the percentage of male smokers (13–15 years old) with a value of 41%, ranking below Papua New Guinea (52.1%), Palau (51.9%) and Samoa (42.2%) . Indonesia is not only a consumer of cigarettes but also a producer of cigarettes, which involves three big tobacco companies that dominate more than 70% of the market share . The production of the tobacco industry is dominated by fulfilling domestic consumers' needs, which amount to 93% of the cigarette sales . This condition occurs because the majority of the tobacco industry produces kretek [cloves], which account for the vast majority of cigarettes smoked (92%) [13,14].
In addition, Indonesia has high numbers of active smokers and also those vulnerable to passive smoke. In 2013, the 0–19 age group became the one most exposed to second-hand smoke . Women, children and toddlers are the group most exposed to cigarette smoke in the home. Those exposed aged 0 to 4 years make up 56%, equivalent to 12 million children exposed to second-hand smoke . The lack of awareness about the danger of second-hand smoke and also the limited number of smoke-free policies thus make women and children prone to illness due to cigarette smoke .
Despite these facts, the implementation of the smoke-free policy at the local level still receives much criticism. A study in Palembang and Bogor showed that both smokers and non-smokers support the adoption of the smoke-free policy, although knowledge about the policy varies . One criticism of the policy is that it does not imply a holistic or comprehensive preventive effort. At the implementation stage, there are still many violations of the smoke-free policy. The commitment of local governments to enforcing the policy also faces many obstacles. Jakarta is one of regions in Indonesia that already had a smoke-free policy before the central government mandated it through the Law on Health (Law No. 36/2009). Jakarta is also one of the local governments that comprehensively prohibits advertising and promotion of cigarettes in public spaces, such as on billboards. Other regions such as Kulon Progo, Bogor, Padang and Padang Panjang also followed, banning tobacco industry advertising in public spaces.
However, many people still disobey the smoke-free policy in Jakarta. One notable incident was seen in a consumer protest by Elysabeth Ongkojoyo, who posted an online-based petition to protest the behaviour of smokers inside a well-known mall. This protest attracted public attention and had the support of more than 49,000 people who signed the online petition . Similar protests emerged both officially through government-controlled channels and through social media statements. One of them is the protest by the anti-smoking coalition consisting of non-government organisations from the Asosiasi Masyarakat Korban Rokok Indonesia (AMKRI), Forum Warga Kota Jakarta (FAKTA), and Smoke-Free Agent (SFA), which claims alleged maladministration by the Jakarta Province Administration related to the handling of smoke-free policy violations in malls .
The evidence indicates that even though there is growing number of smoke-free cities, there is limited research conducted to analyse the commitment of local government to adopting a comprehensive smoke-free policy and creating a strong movement to decrease smoking prevalence and prevent the danger of second-hand smoke. Therefore, this study uses descriptive research to observe and describe the enactment and implementation of the smoke-free policy in Indonesia.
2. Materials and Method
This study uses descriptive research to observe the enactment and implementation of the smoke-free policy in Indonesia. Its cross-sectional analysis investigates the enactment and implementation of the smoke-free policy at the local government level based on the recapitulation of the policy up to December 2016 and secondary data from previous research studies. Ethical approval is not required in this research because it does not involve humans but primarily studies statistical data and secondary data with no manipulation of any variables.
As of December 2016, 229 districts, municipalities and provinces in Indonesia already had the legal basis for a smoke-free policy. The number consists of 144 districts, 69 cities and 16 provinces. The legal basis includes various types of documents, such as Instruction of Regent/Mayor (6), Governor Instruction (1), Regent/Mayor Regulation (95), Regency/City Regulation (9), Governor Regulation (6), Circular Letter of Regent/Mayor (11) and Mayor Decree (8). This indicates that 47 percent of the provinces and 27 percent of the districts in Indonesia have a smoke-free policy . The total number of smoke-free policies enacted based on this result shows an increase as described in the previous study: in April 2015, only 14.9% of the provinces had a smoke-free policy .
As shown in Figure 2, three provinces compiled a policy before there was a national smoke-free regulation through the Law on Health (Law No. 36/2009). The Provincial Government of DKI Jakarta set up a non-smoking area in 2005 through two types of policy documents: namely, District Regulation No. 2 of 2005 on Pollution Control Air for Outdoor Air and Governor Regulation No. 75 of 2005 on Smoking Areas. This regulation was reinforced and updated through Governor Regulation No. 88/2010 on Non-Smoking Regions, Governor Regulation No. 50 of 2012, Governor Regulation No. 59 of 2013, and District Regulation Draft in 2011 on Smoke-Free Areas. In addition to the Province of DKI Jakarta, the Special Province of Yogyakarta also developed a smoke-free policy in 2007. Following that, in 2008, the Jambi Provincial Government established a smoke-free policy.
The provincial government's initiative to draft a smoke-free policy shows the political will of the local government. The existence of national regulations through the Law on Health (Law No. 36/2009) mandated provincial governments to develop derivative policies at the provincial and district levels. More than 50 percent of the provinces have not compiled documents to follow up on this instruction seven years after implementation of the Law on Health (Law No. 36/2009). However, a growing number of districts have developed a smoke-free policy even without the policy existing at the provincial level. This tendency implies district-level initiative toward tobacco control.
The data shown in Table 1 indicates that the distribution of smoke-free policies in each district/city varies. The three provinces with the highest percentage of districts/cities that have already adopted the smoke-free policy are DKI Jakarta, DIY and Bali. All three provinces have the regulatory base at the provincial level. The number reached 100% of the area (provincial and district level) having adopted the smoke-free policy. DKI Jakarta and DIY are examples of two provinces that have the smoke-free policy in all regions and districts, and that initiated the smoke-free policy before any regulation at the national level.
In contrast, the four provinces with the lowest percentage of districts and cities that have smoke-free policies are those that have no smoke-free regulation at the provincial level. The four provinces are NAD, Riau, Papua and West Papua. There is insufficient evidence to show that the existence of smoke-free policies at the provincial level can encourage such policies at the regional level, but the data distribution percentages show that the presence of the smoke-free policy at the provincial level was followed by an increasing number of smoke-free policies at the district level. The data indicates that a high number of districts and cities in Java and Bali have already adopted the smoke-free policy. On the contrary, the four provinces with the lowest percentage of smoke-free adoption are those outside Java (i.e., Sumatera and Papua).
The five provinces with the highest smoking prevalence are West Java, North Maluku, Lampung, Central Sulawesi and Bengkulu. Of the five regions with the highest prevalence of smoking in Indonesia, three do not have a smoke-free policy at the provincial level. In addition, districts and municipalities also have a different smoke-free policy, with the lowest percentage in North Maluku (22.2%). This condition indicates that a smoke-free policy is the basic instrument of intervention to lower smoking prevalence. Governments at all levels need to underline that the smoke-free policy requires comprehensive regulation, and enforcement as a subsequent action. These comprehensive actions need politically driven forces, from leaders to street-level bureaucrats.
This condition is a critique of the implementation of the smoke-free policy in Indonesia. On the regulation side, only a few provinces and districts/cities are implementing the smoke-free policy as a whole. The definition of a smoke-free policy in its entirety is not only to determine that certain public areas ban smoking, but also that there is urgency for preventive activities, especially preventing the sale, purchase, advertising and promotion of cigarettes in the smoke-free area. Up to now, only the Provincial Government of DKI Jakarta, Padang Panjang, Medan and Bogor City have started to initiate banning tobacco industry advertising in public places.
Indonesia's journey to reduce cigarette consumption and control the smoke-free policy faces many obstacles. Regarding regulation, since the issuance of the Law on Health (Law No. 36/2009), many districts, cities and provinces have not adopted the smoke-free policy. Moreover, the smoke-free policy in all regions is still weak compared to the external forces that encourage the increasing prevalence of smoking. This shows that the smoke-free policy has a high linkage with the commitment of the local government leader. The firm commitment of the local administration leader is urgently required to overcome these obstacles.
Local government leaders need to increase tobacco control activities in addition to enacting the smoke-free policy. One criticism as well, as powerfully conveyed by tobacco control activists, is that although there are smoke-free areas, the onslaught of advertising, sponsorship and promotion that became a manifestation of cigarette marketing is very strong. The weak implementation of the smoke-free policy in Indonesia is in line with the results of the smoke-free policy compliance, which indicates that Indonesia's level of compliance is minimal .
In addition to there being regions without a smoke-free policy, there are also law enforcement phenomena related to the smoke-free policy. The Special Region of Yogyakarta is one example of an area that already has an entirely smoke-free area but still allows cigarette advertisements. The provincial and district level in Yogyakarta, in line with the decentralisation of authority in Indonesia, allow the tobacco industry to advertise its products throughout the region .
Advertising is one way the tobacco industry sells its products to various segments by describing cigarettes as a form of cultural change, modernity and globalisation . Cigarette advertisement is very dangerous for youth, because it encourages young people to smoke . Related to this problem, tobacco control activities, which consist of academics, Non-Governmental Organizations (NGOs) and professional organisations, are already expressing their critics and advice to ban tobacco industry advertising .
From a policy perspective, the tobacco control movement faces pressure, with weak regulation of tobacco control in Indonesia because there are no firm attitudes held by stakeholders in this regard. On the other hand, the strength of the tobacco industry and the economic and lobbying sectors poses a significant challenge for tobacco control in Indonesia. One study provided evidence that the cigarette industry, through various promotional and sponsorship activities and through different organisations became the industry's extension to influence tobacco control policymaking in Indonesia . Often the discussion becomes increasingly unclear, because it compares the current income interests of the tobacco industry in Indonesia with the prevalence of smoking. Revenue from the tobacco industry becomes bargaining power that is directly enjoyed by the government.
Efforts to curb the smoke-free policy also need to be anticipated. Bargaining power for the sake of the people must be the first thing people ask about in elections, so that local political leaders dare to innovate. A study found that pro–tobacco industry groups blocked a smoke-free policy in Santa Fe, Argentina . The long journey of drafting regulations for tobacco control in Thailand also underlines the ability of lobbying and the provision of hospitality by the tobacco industry, which can also influence policymaking . The track record of pro–tobacco industry intervention in the formulation of tobacco control policy in Indonesia means that there is a high chance of that policy intervention at the local level.
This study found that the smoke-free policy has a strong linkage with the commitment of the local government leader. However, this breakthrough cannot decrease smoking prevalence without budget allocation support and tobacco control activities, especially for promotion and prevention steps. There is no linear linkage of the smoke-free policy and smoking prevalence, also proving that the smoke-free policy needs politically driven forces, from leaders to street-level bureaucrats. These findings increase our knowledge about the progress of the smoke-free policy in Indonesia and are an essential guide for academics or government officials to conduct research or follow-up enforcement of the implementation of the smoke-free policy.